cardiac death

SCD TEST REQUISITION FORM

LAST NAME

FIRST NAME

DOB (MM/DD/YYYY)

GENETIC SEX

Male female Unknown

MED REC# / PATIENT IDENTIFIER

ETHNICITY

ADDRESS

CITY

STATE / PROVINCE

POSTAL CODE

COUNTRY

PHONE

SAMPLE DRAW DATE(MM/DD/YYYY)

SAMPLE TYPE

Blood Buccal Other:Extracted DNA & DNA

Source

Blood Buccal Tissue Clinical Exome

I have read the Informed Consent document and I give permission to DrSeq to perform genetic testing as described. I also give permission for my specimen and clinical information to be used in de-identified studies at DrSeq and for publication, if appropriate. My name or other persona identifying information will not be used in or linked to the results of any studies and publications. More information is available at www.DrSeq.com

Family History

FAMILY MEMBER 1 NAME

RELATION TO PATIENT

GENETIC SEX

Male Female Unknown

DIAGNOS IS AND / OR SYMPTOMS

AGE OF ON SET

DOB (MM/DD/YYYY)

FAMILY MEMBER 2 NAME

RELATION TO PATIENT

GENETIC SEX

Male Female Unknown

AGE OF ON SET

DIAGNOS IS AND / OR SYMPTOMS

DOB (MM/DD/YYYY)

INSTRUCTIONS

Complete the patient and provider information section.
Read and sign the informed consent policy statement. The complete patient informed consent form for genetic testing
can be found on DrSeq.com. Signature from the provider on Page 1 of the TRF is required for all testing. Signature from
the patient is only required for billing purposes.
Write in the test name and indicate any relevant test options. Please call us if you have any questions.
Add-on any additional genes. Visit our website for our most updated list of 18,000+ available genes.
For Duo/Trio testing, please complete the Family Samples section or submit a separate TRF for each sample.
Please visit DrSeq.com for specimen requirements.
Extracted DNA must extracted from a CLIA-certified laboratory or a laboratory meeting equivalent requirements as determined by CAP and/or CMS.